Endoscopic transnasal approach for retrieval of foreign bodies from the pterygomaxillary fossa

Abstract

Foreign bodies within the aerodigestive tract are common clinical entities, especially in children. Although foreign bodies can be located anywhere along the aerodigestive tract, there are no case reports describing a foreign body within the pterygomaxillary fossa. This area contains numerous vascular and neural structures and can be quite difficult to access. We describe the case of a patient who sustained a gunshot wound to the cheek, wherein the bullet entered the pterygomaxillary fossa. Foreign bodies isolated to the pterygomaxillary fossa can be a challenge to retrieve. Open approaches have been most commonly used, but these approaches often provide limited exposure and can be fraught with complications. We propose the use of a transnasal endoscopic approach for the retrieval of foreign bodies from the pterygomaxillary fossa. 2. Case report The patient is an 18-year-old African American male, who presented to the emergency department at SUNY Upstate Medical University after sustaining a gunshot to the left cheek. The patient complained of left-sided nasal congestion and cheek pain. He denied visual changes, headaches, epistaxis, facial hypoesthesia, difficulty in chewing, dysphagia, malocclusion, or neurological symptoms. Physical examination demonstrated that the patient was awake, alert, and in no acute distress. A 1.5-cm-bullet entry wound with surrounding soft tissue swelling was noted in the left cheek, approximately 4 cm anterior to the tragus. Anterior rhinoscopic examination was normal. The oral cavity examination demonstrated a palpable submucosal firm tooth at the junction of the left hard and soft palate. The tooth socket of the left second upper molar was palpated and noted to be missing a tooth. Cranial nerve exam was normal bilaterally. Rigid nasal endoscopy using a zero-degree, 4-mm endoscope was then carried out on the left side. This demonstrated a shiny bullet lodged within the left lateral nasopharyngeal wall. A computed tomography (CT) scan of the maxillofacial region demonstrated a metallic foreign body wedged in the left pterygomaxillary fossa and lateral aspect of the nasopharynx (Figs. 1 and 2). A molar tooth was noted to be lodged at the junction of the left hard and soft palate. The patient was taken to the operating room for endoscopic removal of the bullet. After the patient was placed under general anesthesia and the endotracheal tube secured in place, a zero-degree, 4-mm endoscope was introduced into the left nasopharynx. The bullet was noted to be wedged in the pterygomaxillary fossa and was visible through a disruption in the lateral nasopharyngeal wall mucosa. A freer elevator was used to dissect the embedded bullet from the lateral nasopharyngeal wall and pterygomaxillary fossa. The bullet had some very sharp edges and was unable to be removed anteriorly because of obstruction from the posterior aspect of the inferior turbinate. A partial inferior turbinectomy was then performed. Despite this, the bullet was still unable to be removed anteriorly without causing significant mucosal lacerations within the nasal cavity. The bullet was then firmly grasped in the nasopharynx using Ferris-Smith forceps. The 30-degree endoscope was then inserted into the posterior oropharynx, and the bullet was visualized in the nasopharynx. The bullet was then delivered into the oropharynx and grasped with another set of forceps. It was then brought out of the oral cavity under endoscopic guidance. It measured approximately 1.5 cm in its greatest dimension (Fig. 3).